The relationship between Psychosomatic Medicine and C-L Psychiatry: an on-going problem

1. WPA International Congress Florence, November 10th-13th, 2004 Symposium “The present and future of C-L Psychiatry” The relationship between Psychosomatic Medicine and C-L Psychiatry: an on-going problem M Rigatelli*, P Gritti**, S Ferrari*, EL Di Caprio** *Department of Psychiatry, University of Modena & Reggio Emilia, Italy **Department of Psychiatry, University of Naples SUN, Italy

2. PM vs. CLP: what relationship? • “Disciplines such as (…) consultation-liaison psychiatry (…) stemmed from the psychosomatic field (…). Their psychosomatic linkages are crucial for their balanced developments”[Fava & Sonino, 2000] • “If general hospital psychiatry was the soil in which the roots of CLP were planted, than PM was the fertilizer that nourished its growth” [Lipsitt, 2001] • “PM refers to a variety of concepts, from holistic health care to biopsychosocial research to consultation-liaison work. CLP is a very specific clinical endeavor that has its roots in GHP, psychobiology and PM” [Ramchadani & Wise, 2004] • “…CLP, a clinical derivative of PM…” [Wise, 2000] PM the Mind, CLP the Arm? Or rather…

3. …The pupil has surpassed the master? Clinical competences of CLP other than psychosomatic syndromes • Psychiatric disorders or behaviours(eg attempted suicide, substance abuse, eating disorders) • Medical-psychiatric comorbidity: • Medical disorders presenting with psychopathologic symptoms (eg delirium) • Medical disorders worsened if psychopathologic symptoms or syndromes occur (eg depression, anxiety, anger…) • Psychic disorders predisposed by medical disorders or therapies (eg cardiovascular disorders, stroke, cancer, psychothropics…) • Liaison activities • Psychopharmacology (interactions, psychic side-effects…) and short psychotherapies • Medical-legal issues

5. A matter of terminology? – 1 • Survey by Thompson [1993]: PM was not even among the 5 options of name considered • The term ‘Psychosomatic’: • “denotes an ill-defined area of interest with poorly defined boundaries (…) implies causation (…) does not convey the range of activities and the current nature of clinical work” [McIntyre, 2002] • often has “negative associations”, and the exclusion of the word ‘psychiatry’ is not acceptable to psychiatrists[Thompson, 1993] • “may (…) threaten the consultation psychiatrist, who is constantly trying to demonstrate the validity of psychiatry within medical settings” [Wise, 2000] • often has a negative connotation among the general public (describes an illness that is imaginary, not important, or even malingered)[Stone et al, 2004]

6. A matter of terminology? – 2 • The term ‘Consultation’ • Merely refers to an action • “is exclusionary and fundamentally an insult to our psychiatric colleagues”[Bronheim, 1992] • The name debate is “a displacement from concerns about the current economics and other stresses of psychiatric practice”[Thompson, 1993] • No term in the end seemed to be entirely satisfying and physicians will in any case continue to call for a “psych consult” [Thompson, 1993] But the name counts! You are what you’re called!…

7. To settle the question once and for all (?!)… …March 2003: The American Board of Medical Specialties finally approves the new subspecialty in Psychosomatic Medicine

8. The subspecialty in PM (US) – 1 • PM is the 7th subspecialty in Psychiatry to be approved: PM and CLP seem to have become two as one: • “PM, also known as CLP” [Levin, 2003] • “PM, sometimes known as CLP” [Hausman, 2002] • “CLP or, as suggested, PM” [Kornfeld, 2002] which IS NOT TRUE! • Psychosomatic MEDICINE is a subspecialty of Psychiatry, or of Internal Medicine, or it is not a sub-specialty of anything, because all medicine should be PM (ie bio-psycho-social), and it is rather a supra-specialty[McKegney et al, 1991]? • The approving process: a 15-year “long-fought battle” [Levin, 2003], accounting for the established position that CL psychiatrists reached through years

9. The subspecialty in PM (US) – 2 • CLP has now to “change its dress” (or rather to disguise itself?), ie change titles of textbooks and of training courses (see what happened at Harvard…) • The (unacceptable) alternative is a plethora of different and competing Services with less and less defined competences (PM, CLP, behavioral medicine, health psychology, clinical psychology…) • Expected an increase in the number of CL fellowship programs and positions [Saravay, 2003], expanded job market and new career opportunities (…), significant increase in interest in CL fellowships [Steinberg, 2003] Maybe new chances, but also…

10. The subspecialty in PM (US) – 3 …The subspecialty in PM may be considered as a cultural defeat for Psychiatry, after the long way that took start from asylums and, within the net of community psychiatry Services, landed to deal with the boundaries of psychiatry (liaison with PC, GH, other Services…)… It is instead, we think, a victoryfor those who didn’t love psychiatry, the psychiatric patient and psychiatrists, who will be accepted only at the condition of changing their nature and name

11. The situation in Europe • UK: a certification process similar to that in the US goes on • Germany: co-existence of CLP (practiced by psychiatrists; focused on psychiatric disorders with organic origin; pharmacological interventions) and PM Services (practiced by internists and psychologists; addressing traditional psychosomatic disorders, somatization, coping; psychological interventions) • Netherlands, UK, Spain, Italy…: no official distinction of Services, depending on local “traditions” • The EACLPP (European Association for Consultation-Liaison Psychiatry AND Psychosomatics): great success of the recent meetings in Zaragoza, Berlin, etc.

12. The relationship between PM and CLP: a summary • No point-to-point correspondence in terms of history and clinical, training and research activities • Subspecialty in PM (in the USA): a cultural defeat for Psychiatry or a historical compromise? • Is there any room in Europe for solutions different from that in the US, which overshadows (CL)Psychiatry? • What solutions can we proposefor today controversies? • Multiprofessional teams vs. multi-services • The leadership (psychiatrists vs. psychologists) • Sharing out of competences – diagnosis, consultation, liaison, psychotherapies, etc… (where multiprofessional teams do exist) • The organisational aspects of liaison with General Hospital and Primary Care Physicians

13. Anyway, at the moment, we can finally state that maybe “the seed, roots and fruit of PM and CLP are inseparable parts of the same plant, in constant commerce with one another. With continuos cross-pollination, both will reap large harvests”[Levenson, 1994; Lipsitt, 2001] Since 1989, the official name of the Modena CLP Service has been: “Psychiatric AND Psychosomatic Consultation Service” Serendipity or foresight?!!